title: Two cases of Bezold-Jarisch reflex induced by intra-arterial nitroglycerin in critical left main coronary artery stenosis.
abstract: The Bezold-Jarisch reflex, a well-described phenomenon, occurs upon the stimulation of intracardiac mechanoreceptors and is mediated by vagal afferent nerve fibers. Several factors can sensitize the cardiovascular system to develop this reflex, including acute myocardial ischemia, natriuretic peptides, and, rarely, nitroglycerin administration in the setting of acute myocardial infarction. The development of the Bezold-Jarisch reflex in the presence of severe coronary artery stenosis, specifically left main coronary artery stenosis, has not been described. We report 2 cases of patients who underwent elective coronary angiography and were given intra-arterial nitroglycerin during radial sheath insertion to reduce radial artery spasm. In both patients, bradycardia and hypotension developed along with diaphoresis, consistent with the Bezold-Jarisch reflex. Coronary angiography revealed critical (>90%) left main coronary artery stenosis in both patients. Critical left main coronary artery stenosis might sensitize mechanoreceptors or vagal afferents to the development of the Bezold-Jarisch reflex after intra-arterial nitroglycerin use; however, the mechanism of this possible relationship is unclear. In addition to discussing our patients' cases, we review the medical literature relevant to the Bezold-Jarisch reflex.
authors.affiliation: Department of Cardiovascular Medicine (Drs. Shah and Waxman), Lahey Clinic, Burlington, Massachusetts 01805; and Tufts University School of Medicine (Dr. Waxman), Boston, Massachusetts 02111.
authors.forename: Sachin P
authors.initials: SP
authors.lastname: Shah
authors.forename: Sergio
authors.initials: S
authors.lastname: Waxman
mesh_terms: D000368:Aged; D001919:Bradycardia / Q000139:chemically induced* / Q000175:diagnosis / Q000503:physiopathology; D017023:Coronary Angiography / Q000009:adverse effects*; D023921:Coronary Stenosis / Q000000981:diagnostic imaging*; D003329:Coronary Vasospasm / Q000209:etiology / Q000517:prevention & control*; D006801:Humans; D007022:Hypotension / Q000139:chemically induced* / Q000175:diagnosis / Q000503:physiopathology; D008297:Male; D008465:Mechanoreceptors / Q000187:drug effects; D008875:Middle Aged; D005996:Nitroglycerin / Q000008:administration & dosage / Q000009:adverse effects*; D011237:Predictive Value of Tests; D012018:Reflex / Q000187:drug effects*; D012307:Risk Factors; D012720:Severity of Illness Index; D014630:Vagus Nerve / Q000187:drug effects / Q000503:physiopathology; D014665:Vasodilator Agents / Q000008:administration & dosage / Q000009:adverse effects*
chemical_list: D014665:Vasodilator Agents; D005996:Nitroglycerin
keywords: Blood pressure/physiology; bradycardia/chemically induced; heart rate/drug effects; hypotension/chemically induced; nitroglycerin/adverse effects; reflex/drug effects/physiology